Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD

Facility

$2,837.00

Service Code	CPT 30901
Hospital Revenue Code	360
Min. Negotiated Rate	$44.33
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$44.33
Rate for Payer: UnitedHealthcare Medicare	$157.18

CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE

Facility

$2,837.00

Service Code	CPT 42960
Hospital Revenue Code	360
Min. Negotiated Rate	$113.60
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$637.13
Rate for Payer: AlohaCare Medicare	$637.13
Rate for Payer: Devoted Health Medicare	$700.84
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$637.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$637.13
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$637.13
Rate for Payer: Ohana Health Plan Medicaid	$700.84
Rate for Payer: Ohana Health Plan Medicare	$637.13
Rate for Payer: UnitedHealthcare Medicaid	$113.60
Rate for Payer: UnitedHealthcare Medicare	$637.13

CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE

Facility

$5,812.67

Service Code	APR-DRG 3843
Min. Negotiated Rate	$5,812.67
Max. Negotiated Rate	$5,812.67
Rate for Payer: AlohaCare Medicaid	$5,812.67
Rate for Payer: Hawaii Medical Service Association ABD	$5,812.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,812.67
Rate for Payer: Kaiser Permanente Medicaid	$5,812.67
Rate for Payer: Ohana Health Plan Medicaid	$5,812.67
Rate for Payer: UnitedHealthcare Medicaid	$5,812.67

CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE

Facility

$3,943.37

Service Code	APR-DRG 3842
Min. Negotiated Rate	$3,943.37
Max. Negotiated Rate	$3,943.37
Rate for Payer: AlohaCare Medicaid	$3,943.37
Rate for Payer: Hawaii Medical Service Association ABD	$3,943.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,943.37
Rate for Payer: Kaiser Permanente Medicaid	$3,943.37
Rate for Payer: Ohana Health Plan Medicaid	$3,943.37
Rate for Payer: UnitedHealthcare Medicaid	$3,943.37

CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE

Facility

$3,016.98

Service Code	APR-DRG 3841
Min. Negotiated Rate	$3,016.98
Max. Negotiated Rate	$3,016.98
Rate for Payer: AlohaCare Medicaid	$3,016.98
Rate for Payer: Hawaii Medical Service Association ABD	$3,016.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,016.98
Rate for Payer: Kaiser Permanente Medicaid	$3,016.98
Rate for Payer: Ohana Health Plan Medicaid	$3,016.98
Rate for Payer: UnitedHealthcare Medicaid	$3,016.98

CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE

Facility

$10,712.44

Service Code	APR-DRG 3844
Min. Negotiated Rate	$10,712.44
Max. Negotiated Rate	$10,712.44
Rate for Payer: AlohaCare Medicaid	$10,712.44
Rate for Payer: Hawaii Medical Service Association ABD	$10,712.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,712.44
Rate for Payer: Kaiser Permanente Medicaid	$10,712.44
Rate for Payer: Ohana Health Plan Medicaid	$10,712.44
Rate for Payer: UnitedHealthcare Medicaid	$10,712.44

CONVERT NEPHROSTOMY CATHETER TO NEPHROURETERAL CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, VIA PRE-EXISTING NEPHROSTOMY TRACT

Facility

$5,509.00

Service Code	CPT 50434
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$2,469.46

COOK VASCULAR DILATORS 20/22

Facility

$761.00

Hospital Revenue Code	272
Min. Negotiated Rate	$646.85
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$456.60
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: MDX Hawaii PPO	$738.17

COOK VASCULAR DILATORS 20/22

Facility

$761.00

Hospital Revenue Code	272
Min. Negotiated Rate	$388.11
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$456.60
Rate for Payer: Hawaii Western Management Group Commercial	$722.95
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Kaiser Permanente Commercial	$479.43
Rate for Payer: Kaiser Permanente Medicaid	$388.11
Rate for Payer: MDX Hawaii PPO	$738.17
Rate for Payer: University Health Alliance Commercial	$554.69

COOLER W/ ADAPTER 51A

Facility

$247.00

Hospital Revenue Code	272
Min. Negotiated Rate	$209.95
Max. Negotiated Rate	$239.59
Rate for Payer: Cash Price	$148.20
Rate for Payer: Health Management Network Commercial	$209.95
Rate for Payer: MDX Hawaii PPO	$239.59

COOLER W/ ADAPTER 51A

Facility

$247.00

Hospital Revenue Code	272
Min. Negotiated Rate	$125.97
Max. Negotiated Rate	$239.59
Rate for Payer: Cash Price	$148.20
Rate for Payer: Hawaii Western Management Group Commercial	$234.65
Rate for Payer: Health Management Network Commercial	$209.95
Rate for Payer: Kaiser Permanente Commercial	$155.61
Rate for Payer: Kaiser Permanente Medicaid	$125.97
Rate for Payer: MDX Hawaii PPO	$239.59
Rate for Payer: University Health Alliance Commercial	$180.04

COONS TAPER DILATOR G03928

Facility

$104.00

Hospital Revenue Code	272
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: MDX Hawaii PPO	$100.88

COONS TAPER DILATOR G03928

Facility

$104.00

Hospital Revenue Code	272
Min. Negotiated Rate	$53.04
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$62.40
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$65.52
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: University Health Alliance Commercial	$75.81

CORD BIPOLAR SYMMETRY

Facility

$156.00

Hospital Revenue Code	272
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: MDX Hawaii PPO	$151.32

CORD BIPOLAR SYMMETRY

Facility

$156.00

Hospital Revenue Code	272
Min. Negotiated Rate	$79.56
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$93.60
Rate for Payer: Hawaii Western Management Group Commercial	$148.20
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Kaiser Permanente Commercial	$98.28
Rate for Payer: Kaiser Permanente Medicaid	$79.56
Rate for Payer: MDX Hawaii PPO	$151.32
Rate for Payer: University Health Alliance Commercial	$113.71

CORKSCREW 6.5 #AR-1927BCF-65

Facility

$1,348.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$754.88
Max. Negotiated Rate	$1,307.56
Rate for Payer: Cash Price	$808.80
Rate for Payer: Hawaii Western Management Group Commercial	$943.60
Rate for Payer: Health Management Network Commercial	$1,145.80
Rate for Payer: MDX Hawaii PPO	$1,307.56
Rate for Payer: University Health Alliance Commercial	$754.88

CORKSCREW 6.5 #AR-1927BCF-65

Facility

$1,348.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$687.48
Max. Negotiated Rate	$1,307.56
Rate for Payer: Cash Price	$808.80
Rate for Payer: Hawaii Western Management Group Commercial	$943.60
Rate for Payer: Health Management Network Commercial	$1,145.80
Rate for Payer: Kaiser Permanente Commercial	$849.24
Rate for Payer: Kaiser Permanente Medicaid	$687.48
Rate for Payer: MDX Hawaii PPO	$1,307.56
Rate for Payer: University Health Alliance Commercial	$754.88

CORKSCREW NANO 3-0 AR-1317FT

Facility

$1,824.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,021.44
Max. Negotiated Rate	$1,769.28
Rate for Payer: Cash Price	$1,094.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,276.80
Rate for Payer: Health Management Network Commercial	$1,550.40
Rate for Payer: MDX Hawaii PPO	$1,769.28
Rate for Payer: University Health Alliance Commercial	$1,021.44

CORKSCREW NANO 3-0 AR-1317FT

Facility

$1,824.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$930.24
Max. Negotiated Rate	$1,769.28
Rate for Payer: Cash Price	$1,094.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,276.80
Rate for Payer: Health Management Network Commercial	$1,550.40
Rate for Payer: Kaiser Permanente Commercial	$1,149.12
Rate for Payer: Kaiser Permanente Medicaid	$930.24
Rate for Payer: MDX Hawaii PPO	$1,769.28
Rate for Payer: University Health Alliance Commercial	$1,021.44

CORONARY BYPASS W AMI OR COMPLEX PDX

Facility

$23,233.45

Service Code	APR-DRG 1652
Min. Negotiated Rate	$23,233.45
Max. Negotiated Rate	$23,233.45
Rate for Payer: AlohaCare Medicaid	$23,233.45
Rate for Payer: Hawaii Medical Service Association ABD	$23,233.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23,233.45
Rate for Payer: Kaiser Permanente Medicaid	$23,233.45
Rate for Payer: Ohana Health Plan Medicaid	$23,233.45
Rate for Payer: UnitedHealthcare Medicaid	$23,233.45

CORONARY BYPASS W AMI OR COMPLEX PDX

Facility

$19,895.10

Service Code	APR-DRG 1651
Min. Negotiated Rate	$19,895.10
Max. Negotiated Rate	$19,895.10
Rate for Payer: AlohaCare Medicaid	$19,895.10
Rate for Payer: Hawaii Medical Service Association ABD	$19,895.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,895.10
Rate for Payer: Kaiser Permanente Medicaid	$19,895.10
Rate for Payer: Ohana Health Plan Medicaid	$19,895.10
Rate for Payer: UnitedHealthcare Medicaid	$19,895.10

CORONARY BYPASS W AMI OR COMPLEX PDX

Facility

$28,337.52

Service Code	APR-DRG 1653
Min. Negotiated Rate	$28,337.52
Max. Negotiated Rate	$28,337.52
Rate for Payer: AlohaCare Medicaid	$28,337.52
Rate for Payer: Hawaii Medical Service Association ABD	$28,337.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28,337.52
Rate for Payer: Kaiser Permanente Medicaid	$28,337.52
Rate for Payer: Ohana Health Plan Medicaid	$28,337.52
Rate for Payer: UnitedHealthcare Medicaid	$28,337.52

CORONARY BYPASS W AMI OR COMPLEX PDX

Facility

$38,373.46

Service Code	APR-DRG 1654
Min. Negotiated Rate	$38,373.46
Max. Negotiated Rate	$38,373.46
Rate for Payer: AlohaCare Medicaid	$38,373.46
Rate for Payer: Hawaii Medical Service Association ABD	$38,373.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38,373.46
Rate for Payer: Kaiser Permanente Medicaid	$38,373.46
Rate for Payer: Ohana Health Plan Medicaid	$38,373.46
Rate for Payer: UnitedHealthcare Medicaid	$38,373.46

CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC

Facility

$131,879.70

Service Code	MSDRG 233
Min. Negotiated Rate	$86,958.45
Max. Negotiated Rate	$131,879.70
Rate for Payer: AlohaCare Medicare	$86,958.45
Rate for Payer: Devoted Health Medicare	$95,654.29
Rate for Payer: Hawaii Medical Service Association Commercial	$130,356.95
Rate for Payer: Hawaii Medical Service Association Medicare	$86,958.45
Rate for Payer: Humana Medicare	$86,958.45
Rate for Payer: Kaiser Permanente Commercial	$131,879.70
Rate for Payer: Kaiser Permanente Medicare	$86,958.45
Rate for Payer: Ohana Health Plan Medicare	$86,958.45
Rate for Payer: UnitedHealthcare Medicare	$86,958.45

CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC

Facility

$114,414.19

Service Code	MSDRG 234
Min. Negotiated Rate	$62,134.15
Max. Negotiated Rate	$114,414.19
Rate for Payer: AlohaCare Medicare	$62,134.15
Rate for Payer: Devoted Health Medicare	$68,347.57
Rate for Payer: Hawaii Medical Service Association Commercial	$114,414.19
Rate for Payer: Hawaii Medical Service Association Medicare	$62,134.15
Rate for Payer: Humana Medicare	$62,134.15
Rate for Payer: Kaiser Permanente Commercial	$94,231.57
Rate for Payer: Kaiser Permanente Medicare	$62,134.15
Rate for Payer: Ohana Health Plan Medicare	$62,134.15
Rate for Payer: UnitedHealthcare Medicare	$62,134.15

Know your out-of-pocket cost for care.

All Charges